Original Article
Vision-related quality of life in patients after ocular penetrating injuries
Qualidade de vida relacionada viso em pacientes aps ferimentos oculares penetrantes
Harun Yksel1, Fatih M. Trkc1, Muhammed ahin1, Yasin inar1, Abdullah K. Cing1, Zeynep zkurt1, Yasin Bez2, hsan aa1
ABSTRACT
Purpose: To measure and investigate visual functioning and health-related quality
of life (QOL) in patients after ocular penetrating injuries (OPI).
Methods: Fifty-four adult patients with OPI and 26 healthy control subjects were
enrolled in the study. The National Eye Institute Visual Functioning Questionnaire
(NEI VFQ-25) and the 36-Item Short Form Health Survey (SF 36) were administered.
Sociodemographic and clinical data also were collected. The primary outcome
measures were comparisons and multivariate analysis among groups for the NEI
VFQ-25 and SF 36 subscale scores.
Results: All NEI VFQ-25 scores, except general health, were significantly lower in
the OPI group than those in the control group. All SF 36 scores were significantly
lower in the OPI group than in the control group. The NEI VFQ-25 subscale item
scores showed no significant differences with respect to age, educational level,
or visual acuity in the injured eye. The SF 36 subscale item scores revealed no
significant differences according to gender or educational level.
Conclusions: Patients with OPI have increased psychological symptoms and lower
levels of QOL than healthy control subjects have. Deteriorations in QOL should
be kept in mind when managing patients with OPI.
Keywords: Eye injuries, penetrating; Quality of life; Questionnaires
INTRODUCTION
Ocular trauma, one of the most common causes of visual loss and
impairment, can contribute considerably to a decreased quality of life
(QOL). Among the types of ocular trauma, ocular penetrating injuries
(OPI) are the leading cause of unilateral vision loss. In the United Sta-
tes, the incidence of OPI was reported to be 3.81 per 100,000 persons.
Many of these injuries are preventable(1).
OPI lead to varying degrees of vision loss, depending on the
complications, location, and size of the injury. The majority of people
who suffer OPI are young individuals(2). Therefore, loss of vision and
visual prognosis is more important for a longer life expectancy. Ocular
pathology in young patients does not only affect visual acuity (VA)
but also affects occupational and social functions(3). In the practice
of ophthalmology, visual function tests, such as visual field analysis,
do not provide information about the psychological consequences
of decreased vision and QOL(4,5). To the best of our knowledge, no
published study has examined the impact of OPI on QOL.
In our study, we used the National Eye Institute 25-Item Visual
Function Questionnaire (NEI VFQ-25) and the 36-Item Short Form
Health Survey (SF 36) to better understand the impact of OPI on QOL.
In previous studies, decreases in visual acuity affected NEI VFQ-25
Submitted for publication: November 19, 2013
Accepted for publication: January 3, 2014
Study conducted at Dicle University Faculty of Medicine, Diyarbakir, Turkey.
1
Department of Ophthalmology, Dicle University Faculty of Medicine, Diyarbakir, Turkey.
2
Department of Psychiatry, Dicle University Faculty of Medicine, Diyarbakir, Turkey.
http://dx.doi.org/10.5935/0004-2749.20140024
RESUMO
Objetivo: Medir e investigar a funo visual e a qualidade de vida relacionada sade
(QOL) em pacientes aps ferimentos ocular penetrantes (OPI).
Mtodo: Cinquenta e quatro pacientes adultos com OPI e 26 indivduos saudveis
(controles) foram includos no estudo. O questionrio de funo visual do National Eye
Institute (NEI VFQ-25) e a avaliao curta de 36 itens (Short Form Health Survey - SF 36)
foram administrados. Dados sociais, demogrficos e clnicos tambm foram coletados.
As comparaes e anlise multivariada entre os grupos para as subescalas do NEI
VFQ-25 e do SF 36 foram consideradas como resultados primrios.
Resultados: Todos os ndices do NEI VFQ-25, exceto sade geral, foram significati-
vamente menores no grupo OPI do que aqueles no grupo controle. Todos os ndices
do SF 36 foram significativamente menores no grupo OPI do que no grupo controle.
Os ndices das subescalas do NEI VFQ-25 no apresentaram diferenas significativas
em relao idade, escolaridade, ou acuidade visual no olho ferido. Os ndices das
subescalas do SF 36 no revelaram diferenas significativas de acordo com o nvel de
escolaridade ou sexo.
Concluses: Pacientes com OPI apresentaram sintomas psicolgicos aumentados e
nveis mais baixos de qualidade de vida que os indivduos saudveis. Deterioraes na
qualidade de vida devem ser consideradas ao gerenciar pacientes com OPI.
Descritores: Ferimentos oculares penetrantes; Qualidade de vida; Questionrios
and SF 36 scores(6). NEI VFQ-25 was developed to assess a patients
perception of QOL and visual function, and has been used to assess
the quality of vision in retinal vein occlusion(7), diabetic retinopathy(8),
glaucoma(9), and after ocular surgery(4,5). SF 36 evaluates the effect of
overall health on QOL(10).
Here, we report vision-related QOL (VR-QOL) and health-related
QOL (HR-QOL) in a population of patients with OPI using NEI VFQ-25
and SF 36 questionnaires. To the best of our knowledge, this is the first
study to measure VR-QOL and HR-QOL in patients with OPI.
METHODS
Institutional review board approval was obtained through the
university ethics committee, and the study was conducted in com-
pliance with the Declaration of Helsinki. Written informed consent
was obtained from the participants. This prospective study enrolled
54 patients with OPI who were scheduled for vision care at the De-
partment of Ophthalmology. Patients were enrolled in the study if
they were aged 18 years, at least 6 months into the clinical course
after the injury (to achieve relatively stable results of visual outcomes),
and had no other systemic or ocular disease that could affect vision.
Funding: No specific financial support was available for this study.
Disclosure of potential conflicts of interest: None of the authors have any potential conflicts of
interest to disclose.
Corresponding author: Harun Yksel. Dicle niversitesi Tp Fakltesi - Sur/Diyarbakr, Turkey -
E-mail: drharunyuksel@gmail.com
Arq Bras Oftalmol. 2014;77(2):95-8 95
Vision-related quality of life in patients after ocular penetrating injuries

A complete ophthalmological examination, including visual acuity, significantly lower in the OPI group than in the control group. All
intraocular pressure measurements, and biomicroscopic evalua patients with OPI had sustained an injury in only one eye. The mean
tion of the anterior segment and fundus was performed for all follow-up for patients after surgery was 8.4 3.1 (6-19) months. Male
participants. To correlate visual acuity with subscale responses, the and female patients in the OPI group showed no difference in NEI
Snellen visual acuity of the affected eye was converted to a logMar VFQ-25 and SF 36 scores.
equivalent. A correlation analysis of the NEI VFQ-25 and SF 36 scores, age,
Data, including age, gender, and best-corrected visual acuity, of visual acuity, and gender are presented in table 3. A linear regression
all participants were recorded. All participants completed the SF 36 analysis was performed with the variables that showed a significant
and VFQ-25 questionnaires to evaluate their HR-QOL and VR-QOL, correlation. In the regression analysis, the NEI VFQ-25 composite
respectively. The control group consisted of age, gender, and edu-
cation level matched patients who were admitted to our clinic for
examination with no pathology that affected visual function. Table 1. Demographic characteristics of the ocular penetrating injury
patients and control subjects
Measurements of psychological state and QOL SF 36
OPI n (%) Control n (%) p
SF 36 is the most widely used self-report scale that measures Sex
HR-QOL. It successfully measures the HR-QOL of patients with
medical or psychological disorders, as well as healthy subjects. The Female 12 (22.2) 09 (34.6)
scale can assess the positive and negative aspects of health, and it is Male 42 (77.8) 17 (65.4) 0.238
considered sensitive to small changes in disability status. It was first Duration 8.4 3.1 (6-19) month
developed by Ware and Sherbourne in 1992(10). It provides scores Educational level
ranging between 0 and 100 that represent QOL in eight dimensions
of health (physical functioning, physical role difficulty, bodily pain, Elementary school 02 (03.7) 02 (07.7)
general health perception, vitality, social functioning, emotional role Junior high school 09 (16.7) 04 (15.4) 0.564
difficulty, and mental health). Higher scores reflect a better QOL. The High school 40 (74.1) 20 (76.9)
validity and reliability of the Turkish version of the SF 36 was demons-
logMar VA 0.76 0.89 0.0 0.0 p<0.001
trated by Kocyigit et al. in 1999(11).
Type of the injury
NEI VFQ-25 Corneal 32 (59.3)
NEI VFQ-25 was used to assess VR-QOL in our participants. It is Corneoscleral 09 (16.7)
a validated and reliable instrument that assesses the dimensions of Scleral 13 (24.1)
self-reported and vision-targeted health status, which are most im Age 30.5 8.2 33.0 4.6 0.158
portant for persons with chronic eye disease.
The NEI VFQ-25 has been translated into Turkish, and its reliability
and validity have been established. This version, which was used in
previous studies, was administered to all subjects(12). VR-QOL, which Table 2. Test result of NEI VFQ-25 and SF 36 tests
measures visual functioning level in 12 dimensions, was assessed
using NEI VFQ-25. It generates subscales for the following 12 dimensions Subscale OPI group Control group p value
of VR-QOL: general health, general vision, ocular pain, near activities, NEI VFQ-25 (mean SD) (mean SD)
distance activities, vision-specific social functioning, vision-specific General health 80.1 25.4 091.7 11.7 <0.092
mental health, vision-specific role difficulties, vision-specific depen-
General vision 50.4 18.1 095.4 8.6 <0.001
dency, driving, color vision, and peripheral vision. Finally, an overall
composite score is calculated that serves as an average of all subscales, Ocular pain 58.7 13.6 098.1 6.8 <0.001
excluding the general health subscale. Scores range from 0 to 100, Near activity 54.8 12.3 099.0 3.4 <0.001
with higher scores indicating a better QOL(13). Distance activity 56.5 15.5 097.1 7.0 <0.001

Statistical analysis Social function 63.0 19.9 100.0 0 <0.001

Mental health 53.3 11.4 100.0 0 <0.001
Statistical analysis were performed with Statistical Program for
Social Science version 15 (SPSS, Chicago, Illinois, USA). Independent Role difficulties 52.5 12.9 100.0 0 <0.001
sample t-tests, one-way analysis of variance (ANOVA), correlational Dependency 66.8 17.6 100.0 0 <0.001
analysis, and linear regression were used in the statistical analysis. The Driving (6/13) 56.9 3.4 093.6 7.0 <0.001
data are presented as the mean standard deviation.
Color vision 70.8 17.3 100.0 0 <0.001
Peripheral vision 58.2 21.3 100.0 0 <0.001
RESULTS
Composite score 58.1 21.3 099.8 0.7 <0.001
The study participants included 54 patients who had undergone
SF 36 (mean SD) (mean SD)
surgery because of OPI occurring at least 6 months before the study
began. In addition, we examined 26 healthy control subjects. There Physical functioning 98.2407 3.2443 100.0000 0 <0.001
were no differences between groups in terms of age, gender, or edu- Social functioning 73.3796 21.3139 94.7115 7.2224 <0.001
cation level. The demographic characteristics of the patients and the Physical problems 53.3704 44.1478 97.1154 8.1453 <0.001
control group are given in table 1.
Pain 66.3889 21.9454 87.8462 4.6276 <0.001
SF 36 and NEI VFQ-25 scores are presented in table 2. All NEI VFQ-25
scores, except general health, were significantly lower in the OPI Emotional problems 55.5557 46.2426 100.0000 0 <0.001
group than in the control group. The study participants answered Mental health 65.5556 13.1043 85.2308 5.7432 <0.001
all questions, except driving-related questions. Driving-related Energy and vitality 59.0741 12.4033 83.2692 5.6466 <0.001
questions were answered by only 6 (11%) patients in the OPI group
and 13 (50%) subjects in the control group. All SF 36 scores were General perception of health 48.5556 17.8997 89.1923 8.3331 <0.001

96 Arq Bras Oftalmol. 2014;77(2):95-8

 Yksel H, et al.

score was affected by the final visual acuity, social function, and emo scores. Schareder et al.(16) evaluated patients with open eye injuries
tional status sub-scores of the SF 36 (Table 4). In addition, the final and examined how the trauma affected their work life, QOL, and emo-
visual acuity was affected by the NEI VFQ-25 composite score and tional well-being. They reported that QOL was negatively affected in
initial visual acuity (Table 5). Gender and education level were not patients with an ocular injury. However, in that study they, did not
related to the NEI VFQ-25 composite score or the final visual acuity. report information about their questionnaire; therefore, it is uncertain
if a standard questionnaire was used. In our study, the effect of OPI on
DISCUSSION QOL was analyzed with standard questionnaires and compared with
the QOL of healthy controls.
To our knowledge, the present study is the first to compare the
psychological status and QOL of patients with OPI to those of healthy Patients with vision loss due to ocular trauma not only suffer vision
control subjects. The results of the current study demonstrate that impairments, they also experience deterioration in social functioning
OPI patients have increased psychological symptoms and lower that can decrease labor in the workplace. Many patients with vision
levels of QOL than healthy control subjects. loss cannot continue their employment and need to change their
OPI, which are usually observed in young individuals, is the lea- occupation or obtain disability status(13). Therefore, QOL of those indi-
ding cause of unilateral vision loss; men are more often affected than viduals is seriously affected. In our study, the overall health of patients
women(2). In our study, the male/female ratio was consistent with in the OPI group was affected and the SF 36 scores, which determine
those reported in the literature. However, there was no significant the HR-QOL, were significantly lower in the group than in the con-
effect of gender on QOL. trol group. Rofail et al. compared QOL in patients who underwent
Many studies have found the size and location of the wound are primary or secondary enucleation because of OPI(17). They reported
important indicators for the visual prognosis(2,14). Corneoscleral OPI that QOL was more affected in patients who underwent primary enu-
has a poorer prognosis in terms of visual acuity(14,15). In our study, there cleation than in those who underwent secondary enucleation. They
was no relationship between OPI location and NEI VFQ-25 or SF 36 suggested that, if possible, the eyeball should not be removed during
the primary repair. However, in that study, QOL was not compared
between patients with OPI and control subjects.
Table 3. The correlations between visual acuity, age duration of OPI The NEI VFQ-25 composite scores observed in the present study
with the NEI VFQ-25* scores were lower than those reported for patients with PDR, SMD, or Behets
Visual acuity Age disease in other studies(8,18,19). Our patients were younger than those
Test scores r p r p in other studies; therefore, young individuals may experience a greater
General health -0.507 <0.001 -0.271 0.279 impact on their QOL with permanent vision loss due to trauma than
with other diseases. The NEI VFQ-25 scores for a younger patient group
General vision -0.582 <0.001 -0.311 0.122
with ocular chemical burns reported in a study(13) were similar to
Ocular pain -0.224 0.103 -0.224 0.271 those observed in our study. In that study, patients with bilateral
Near activity -0.386 0.004 -0.200 0.327 injuries had severely decreased composite scores in NEI VFQ-25(16).
Distance activity -0.496 <0.001 -0.353 0.077 No patient had bilateral trauma in our study.
Social function -0.468 <0.001 -0.433 0.027 Using NEI VFQ-25, Onal et al. reported that general health was
more influenced than general vision in patients with Behets disea
Mental health -0.443 0.001 -0.296 0.141
se(18). In contrast, the present study found that OPI affected vision
Role difficulties -0.437 0.001 -0.240 0.238 more than general health. We suggest that this difference is based
Dependency -0.477 <0.001 -0.171 0.403 on the systemic involvement of the Behets disease, whereas OPI is
Color vision -0.402 0.430 -0.097 0.637 usually localized to one eye.
Peripheral vision -0.178 0.197 -0.111 0.591 Previous reports indicated that QOL is affected by ocular disea-
ses(18,20,21). In this study, SF 36, a widely known instrument, was used
Composite score -0.574 <0.001 -0.393 0.047
to assess HR-QOL. Using the same questionnaire, QOL changes were
*NEI VFQ-25= National Eye Institute Visual Functioning Questionnaire.
reported with central serous chorioretinopathy, age-related macular
degeneration, and Behets disease(8,18,20). In our patients first VA exam,
the composite score of NEI VFQ-25 and the mental health score of
Table 4. Regression analysis of the factors that were found to be effective SF 36 affected the final VA. Level of education, age, and gender had
on composite score of NEI VFQ-25* in a univariate analysis no effect on the final VA. In contrast to Onal et al., who reported that
Beta t p value education level and age affected the visual prognosis in Behets
Social function 0.850 11.64 0.000
disease(15); another study found that education, general vision, near
vision, and social functioning scores decreased. They suggested that
Final visual acuity 0.555 06.09 0.000
a high level of education increases the patients awareness and
Emotional score of SF 36 0.273 02.28 0.027 knowledge of their disease.
Dependent variable= composite score of VFQ 25 r2=0.81. In this study, we showed that OPI patients showed poorer vision
*NEI VFQ-25= The National Eye Institute Visual Functioning Questionnaire. and health-related QOL than healthy subjects. In addition, general
vision was more affected than general health in patients with OPI.
Furthermore, deterioration in QOL should be considered in patients
Table 5. Regression analysis of the factors that were found to be effective with OPI. Deterioration in QOL may lead to psychiatric disorders. Pa-
on final visual acuity in a univariate analysis tients should be evaluated in this aspect and psychiatric help should
Beta t p value
be given when necessary.
Composite score of NEI VFQ-25* -0.810 -9.942 0.000
First visual acuity -0.231 -2.404 0.020 ACKNOWLEDGMENT
Dependent variable is final visual accuity. r2=0.66. We are grateful to Dicle University DUBAP for their sponsorship
*NEI VFQ-25= The National Eye Institute Visual Functioning Questionnaire. about English editing of this manuscript.

Arq Bras Oftalmol. 2014;77(2):95-8 97

Vision-related quality of life in patients after ocular penetrating injuries
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